The Proof is in the Pudding - 0 Post Op Adhesions Using the ME Protocol
And why it works so well all the time
Some time back we performed one of the most gratifying surgeries of the recent years. Patients come to Mayflower from all over the country and the world. Post surgery, when they go back, we rarely get to observe them in an operative state again. When they conceive they stick to their friendly neighbourhood gynaecologist.
This time however, we had an endometriosis patient from over a year ago. May 2024 to be precise. She came down for her C-Section surgery. And what we saw when we peeked into the abdomen completely blew us away.
In today’s edition, you will see the extent of endometriosis involvement that she showed just a little over a year ago, and how her body responded when treated under the ME (Mayflower Endometriosis) Protocol, giving a surprisingly clear and adhesion free mayoterium.
Let’s begin with the endometriosis surgery. This was no mean feat. It was a full fledged extensive surgery.
We dissected the ovary for endometriomas
Performed some parametrial nodule removal, and uretrolysis
The disease took us all the way to recto-vaginal nodule removal, medial para-rectal space dissection, and a shaving off of a rectal nodule. Closed with suturing.
It was a grand standing case of deep infiltrating endometriosis.
Once done, the patient recovered and went back to following the ME Protocol. A key reason we believed she presented soon after with a healthy baby and zero adhesions.
The ME Protocol
Short for the Mayflower Endometriosis Protocol for Fertility Intent in Endometriosis, ME Protocol was developed with an intent to see how far we can go in achieving a complete removal of the disease.
This protocol has four primary steps
Total and restorative fertility preserving and enhancing surgery
Clinically induced amenorrhea
Fertility planning - natural + assissted
Gestational and lactational amenorrhea
Natural Conception
The patient we’re referring to here conceived naturally. As have over 45% of people all who underwent DIE surgery with a fertility intent at Mayflower. It’s all possible because the four specific steps help build a solid foundation for healing, recovery, and restoration.
Let’s look at the significance each step has in the process
Total and restorative fertility preserving and enhancing surgery
We’ve written quite extensively about recurrence reducing procedures in our previous editions. While the Mayflower Butterfly Peritonectomy is exclusively focused on reducing recurrence, the Sanjay Patel Classification of Adenomyosis and its related procedures, together with the Five Levels of Ureteric Dissection help in anatomical restoration.
The goal is get as much of the disease out as possible, from as many places as it might be present while preserving and/or enhancing the fertility prospect of the patient. The only tissues left behind are microscopic implants that are imperceptible both to the human eye and to conventional MRI.
Clinically induced amenorrhea - 6 months
This is followed by a clinically induced amenorrhea. We practice giving Leuprolide post recovery from surgery since it’s a single shot injectable that leads to ~6 months of amenorrhea, however side effects considered, some cases fare better with a Dienogest 2mg prescription.
This practice gives the body time to recover and recuperate from the trauma of surgery at sites that were earlier highly active through the ups and downs of hormones in any given month.
Fertility Planning - Natural + Assisted - 3 months
We typically counsel couples (open to considering pregnancy) to begin trying for conception immediately after the natural cycle resumes. We typically give them three months to attempt a natural pregnancy. If it is already known that the likelihood of a natural pregnancy is low, they may be advised to go for IVF.
Either way, conception is pursued.
In an observation of 617 patients of fertility enhancing endometriosis surgeries between 2019 and 2021, it was found that 45% were able to conceive naturally after surgery.
This was possible because of a complete surgery with steps including complete removal of endometriotic cysts from ovaries (not simply drain them), reestablishment of a good tube-ovarian relationship, and other procedures that enhance and preserve fertility.
Of the 55% unable to conceive naturally, 42% were able to conceive in the first cycle of IVF and subsequently another 32% conceived upto the third cycle.
Gestational and Lactational Amenorrhea - 22 months
A successful pregnancy further leads to 9 months of gestational and 12 months of lactational amenorrhea. This we believe is the strongest agent of recovery. All the microscopic implants that were inadvertently left behind in surgery, the seeds of future recurrence, spend almost 30 months with little hormonal concentration to induce growth.
In this 27 month period, it is likely that the body’s immune system recognises the ectopic nature of these tissues and causes apoptosis over a period of time, rendering them incapable of growth once the hormones come back.
The ME Protocol put together with our data on radical surgeries has given us a net recurrence of 1.8% against a global average of 40+%
It is likely that more than one factor is at play in reducing recurrence, but we are significantly convinced that pregnancy has a big role to play there.
The Grand Reveal
Just a few weeks back in August, she underwent C-Section at our institute and in the procedure we found no adhesions on the uterus. No residual plaque whatsoever.
I’ve had this conversation many times with other doctors who believe that extensive and thorough surgeries increase the chances of post-operative adhesions as the body begins to heal. But that’s really not true. At least not conclusively. This here is a case in point.
Here’s why I think that might be the case
1. Reperitonization Begins Early
The peritoneum has a remarkable regenerative capacity.
Reperitonization starts within 24 hours post-surgery, with mesothelial cells migrating across raw surfaces to re-establish the peritoneal layer.
By day 5–7, most denuded areas are covered, drastically reducing the risk of adhesions.
2. Correct Planes and Surgical Principles Matter
When dissections are done in the correct anatomical planes (respecting avascular spaces, preserving tissue integrity, and avoiding unnecessary thermal injury):
Bleeding and tissue ischemia are minimized.
Inflammatory stimulus for adhesion formation is reduced.
Meticulous haemostasis, atraumatic handling, and liberal irrigation further prevent adhesion formation.
3. Role of Blastocytic and Blastoclastic Activity
After peritoneal injury, blastocytic (fibroblast proliferation and collagen deposition) and blastoclastic (matrix remodeling and resorption) activities occur in balance.
In correct surgical planes, blastocytic activity closes potential spaces by laying down healthy collagen scaffolding, while blastoclastic activity remodels and removes excess extracellular matrix.
This self-regulating repair minimizes the persistence of raw surfaces that can tether and form adhesions.
However, if dissection is rough, thermal injury is excessive, or devascularized tissue remains, excess fibroblastic response can outpace remodeling, increasing adhesions.
This case, in line with several others, reinforces our belief in the ME Protocol and in the philosophy or anatomy restoring complete disease removal.
That’s it for this week. We’ll see you in the next one.
 | A guest post by
|
 | A guest post by
|